發(fā)布時(shí)間：2018-09-15 05:58

【摘要】：兒童結(jié)核病臨床表現(xiàn)不典型，并且多表現(xiàn)為結(jié)核性腦膜炎、血行播散性結(jié)核和肺外結(jié)核等重癥結(jié)核，形勢嚴(yán)峻，已逐漸成為我國結(jié)核防治中的難題。目的針對(duì)以重慶醫(yī)科大學(xué)附屬兒童醫(yī)院1360例兒童結(jié)核住院病人的資料做分析，總結(jié)各型結(jié)核的臨床特征，提高診斷意識(shí)和手段，，減低誤診率，并對(duì)我院的治療效果初步總結(jié)。方法回顧性分析我院1360份兒童結(jié)核病病歷的一般情況、臨床癥狀、體格檢查、實(shí)驗(yàn)室資料及影像學(xué)資料。結(jié)果1.男性664例（58.8%），女性465例（41.2%），男性患兒明顯多于女性患兒。0-2歲、11-13歲為兩個(gè)好發(fā)年齡高峰，且男性患兒與女性患兒的發(fā)病年齡均值分別為6.0歲、6.8歲，兩者有顯著差異；患兒中來自農(nóng)村者高于在城鎮(zhèn)患兒；38.8%的患兒有明確結(jié)核病人接觸史。2.卡介苗可以有效降低血行播散型肺結(jié)核、結(jié)核性腦脊膜炎的發(fā)生。3.血清結(jié)核抗體陽性率約10.8%，分泌物結(jié)核桿菌PCR陽性17例（25%），痰、胃液涂片陽性276/679例（40.6%），痰、胃液培養(yǎng)陽性131/583例（22.5%），手術(shù)病檢確診163例（91.6%）。4.影像學(xué)檢查及其他檢查：胸部改變以右肺為主；頭顱CT中改變最明顯為腦室豐滿或擴(kuò)大（55.1%）、腦積水（49.7%）、基底節(jié)區(qū)病變（42.2%），以上表現(xiàn)合并者也多見。纖支鏡對(duì)結(jié)核感染診斷率較高，提示結(jié)核感染15例，占53.6%。5.首次住院患兒中，確診為肺結(jié)核患者有832例（73.7%），其中原發(fā)性肺結(jié)核病變?yōu)?63例（31.6%）；繼發(fā)型肺結(jié)核230例（27.6%）；結(jié)核性胸膜炎230例（27.6%）；血源播散性肺結(jié)核210例（25.2%）。6.肺外結(jié)核中，結(jié)核性腦脊髓炎432例（38.3%）；腹腔結(jié)核142例（12.6%）；骨關(guān)節(jié)結(jié)核115例（10.2%）；淋巴結(jié)結(jié)核57例（5.0%）；泌尿系、生殖系結(jié)核23例（2.0%）；支氣管內(nèi)膜結(jié)核14例（1.2%），其他耳部、心包、皮膚等感染32例。7.粟粒性肺結(jié)核好發(fā)年齡為0-6月；繼發(fā)性肺結(jié)核好發(fā)年齡無顯著差別；原發(fā)性肺結(jié)核好發(fā)年齡為1歲以后兒童，結(jié)核性腦脊膜炎在6月-3歲為好發(fā)年齡段；骨關(guān)節(jié)結(jié)核1-6歲為好發(fā)年齡段；腹腔結(jié)核、結(jié)核性胸膜炎、泌尿系統(tǒng)結(jié)核好發(fā)年齡均為12-18歲。8.正規(guī)抗結(jié)核治療同時(shí)加用小劑量激素可增加血行播散型肺結(jié)核、結(jié)核性胸膜炎、結(jié)核性腦脊膜炎、腹腔結(jié)核的好轉(zhuǎn)率（均采用卡方檢驗(yàn)，P＜0.05）。結(jié)論我院兒童結(jié)核的臨床分析與國內(nèi)外文獻(xiàn)報(bào)道大致相同，但我院結(jié)核性腦脊膜炎患兒發(fā)病率較高，骨關(guān)節(jié)結(jié)核發(fā)病率較低。一般治療效果較好，好轉(zhuǎn)率為70.5%，但結(jié)核性腦脊膜炎死亡率較高（6.0%）。目前兒童結(jié)核感染形勢嚴(yán)峻，患兒病程長，病原學(xué)陽性率低，需加強(qiáng)對(duì)臨床、實(shí)驗(yàn)室檢測、影像學(xué)綜合分析，必要時(shí)可積極行診斷性治療。
[Abstract]:The clinical manifestation of child tuberculosis is not typical, and most of them are tuberculous meningitis, disseminated tuberculosis and extrapulmonary tuberculosis. The situation is severe and has gradually become a difficult problem in the prevention and treatment of tuberculosis in China. Objective to analyze the data of 1360 hospitalized children with tuberculosis in the Children's Hospital affiliated to Chongqing Medical University, summarize the clinical characteristics of various types of tuberculosis, improve the diagnostic awareness and means, reduce the misdiagnosis rate, and preliminarily summarize the therapeutic effect of our hospital. Methods the general situation, clinical symptoms, physical examination, laboratory data and imaging data of 1360 cases of tuberculosis in children in our hospital were retrospectively analyzed. Result 1. There were 664 males (58.8%) and 465 females (41.2%). There were significant differences between males and females. 38.8% of children from rural areas had definite history of contact with tuberculosis. BCG can effectively reduce blood disseminated pulmonary tuberculosis, tuberculous meningitis. 3. 3. The positive rate of tuberculosis antibody in serum was about 10.8%, the positive rate of PCR in secretion was 25%, the positive rate of sputum and gastric smear was 276 / 679 (40.6%), the positive rate of sputum and gastric juice culture was 131 / 583 (22.5%), and the diagnosis of operation was 163 (91.6%) .4. Imaging examination and other examinations: the chest changes were mainly in the right lung, the most obvious changes in CT were ventricular fullness or enlargement (55.1%), hydrocephalus (49.7%), basal ganglia lesions (42.2%). The diagnostic rate of tuberculosis infection by fiberoptic bronchoscopy was higher, suggesting that 15 cases (53.6%) had tuberculosis infection. Among the first hospitalized children, 832 cases (73.7%) were diagnosed as pulmonary tuberculosis, including 263 cases (31.6%) with primary pulmonary tuberculosis, 230 cases (27.6%) with secondary pulmonary tuberculosis, 230 cases (27.6%) with tuberculous pleurisy, 210 cases (25.2%) with hematogenous disseminated pulmonary tuberculosis. Among them, 432 (38.3%) were tuberculous encephalomyelitis, 142 (12.6%) were celiac tuberculosis, 115 (10.2%) were osteoarticular tuberculosis, 57 (5.0%) were lymph node tuberculosis, 23 (2.0%) were tuberculosis of urinary system and genital system, 14 cases (1.2%) of endobronchial tuberculosis, and 14 cases (1.2%) of endobronchial tuberculosis, other ear, pericardium, pericardium and pericardium. 32 cases of skin infection. The age of onset of miliary pulmonary tuberculosis was 0-6 months, the age of secondary pulmonary tuberculosis was not significantly different, the age of primary pulmonary tuberculosis was after 1 year old, and the age of tuberculous meningitis was 3 years old in June. Osteoarticular tuberculosis (1-6 years old), abdominal tuberculosis, tuberculous pleurisy (TB), and urinary tuberculosis (age 12-18 years). The improvement rate of disseminated pulmonary tuberculosis, tuberculous pleurisy, tuberculous meningitis and intraperitoneal tuberculosis was increased by regular anti-tuberculosis therapy and low dose hormone (all P < 0.05 by chi-square test). Conclusion the clinical analysis of tuberculosis in children in our hospital is almost the same as that reported in domestic and foreign literatures, but the incidence of tuberculous meningitis in our hospital is higher and the incidence of tuberculosis of bone and joint is lower. The cure rate was 70.5%, but the mortality rate of tuberculous meningitis was higher (6.0%). At present, the situation of tuberculosis infection in children is severe, the course of disease is long and the positive rate of etiology is low. It is necessary to strengthen the comprehensive analysis of clinic, laboratory examination, imaging and, if necessary, to actively carry out diagnostic treatment.
【學(xué)位授予單位】：重慶醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2012
【分類號(hào)】：R529.9

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